2010 - The War Veterans´ silent killers.

by Eduardo C. Gerding

Published at

The International Review of the Armed Forces Medical Services- September 2010-Vol 83/3

Summary

Hace veintisiete años fuerzas argentinas y británicas se enfrentaron en lo que se considera fue la ultima guerra colonial del Reino Unido77,99 .Los combatientes de ambos lados enfrentan hoy día un enemigo común: las enfermedades cardiovasculares (ECV) que habrán de hacerse mas evidentes a medida que pasen los años.Argentina y el Reino Unido presentan muchas semejanzas en cuanto a prevalencia de Factores de Riesgo (CRF).Los efectos psicológicos a largo plazo del conficto de 1982 estan asociados a las enfermedades cardiovasculares. Los efectos psicológicos pueden actuar como desencadenantes de episodios cardíacos agudos.

Twenty seven years ago Argentine and British forces collided in what was considered Great Britain´s last colonial war 77,99. Combatants of both sides face now a common foe:Cardiovascular diseases(CVD)which will become more evidente as the years go by.Argentina and United Kingdom have great similarities regarding coronary Risk Factors(RF). The late psychological effects of the 1982 conflict are linked to CVDs. The psychological effects may even trigger acute cardiac events.

Cardiovascular disease (CVD)

Cardiovascular disease (CVD) is any disease of the circulatory system. Most of the deaths from CVD relate to coronary heart disease (CHD or heart attack), stroke (Cerebrovascular disease) and other diseases of the circulatory system including heart failure and diseases of the arteries. 97 .A major study, conducted by researchers at the Harvard School of Public Health in Boston (USA), of about 2000 military veterans who served in the armed forces during WWII proves that they suffer from symptoms/of post-traumatic stress disorder (PTSD).The study also suggests that they stand a greater risk of heart disease as their live unfold. 106 .

In Russia, veterans of the Great Patriotic war have shown an earlier development of ischemic heart disease, arterial hypertension, and cerebral atherosclerosis. 6 .Cohen et al studied Veterans of the US Wars in Afghanistan and Iraq using the Department of Veterans Affair(VA)healthcare system for the first time, who were mostly in their 20s and 30s were significantly more likely to display certain cardiovascular-disease risk factors if they had received a mental-health diagnosis such as depresión, anxiety disorder, or (PTSD) 24. The Commitee on Gulf War and Health has stated that many of the studies published so far  were cross sectional and couldn´t fully assess symptom duration and chronicity, latency of onset, and prognosis. 

This was an important limitation because many of the long-term outcomes such as coronary heart disease and cancer have long latent periods of decades.46,55. No studies have been made so far regarding the actual and future risk of cardiovascular health of Argentine and British war veterans who took part in the 1982 conflict. We could very well quote Patrick and Heaf in as far as there is is ¨a paucity of research on war victims¨ 81. 


Coronary Heart Disease (CHD)

CHD is a disease that affects the heart muscle and the blood vessels.The most serious danger of CHD is a heart attack, which occurs when the supply of blood to the heart is greatly reduced or stopped due to a blockage in a coronary artery. 97 .By the time Argentine war veterans have 66 years old it is expected that 7 of every ten deaths will be due to non transmitable diseases; among them coronary heart disease (CHD) will be the main cause and stroke the fourth 41.

Congestive Heart Failure (CHF)

CHF is a disorder where the heart loses its ability to pump blood efficiently,leading to problems like fatigue and shortness of breath. CHF is not a single disease but the end stage of many different forms of heart disease. The most common of these is CHD.

CVD Mortality
 
According to the American Heart Association about 82% of people who die of coronary heart disease are 65 or older. 1
CVD are the first cause of mortality and morbidity in Argentina . 83. In 2007, of 290,911 deaths in Argentina, 95.420 were due to CVD 89. There are 42,000. myocardial infarcts (MI) per year in Argentina.88. Cardiovascular diseases are the first cause of mortality in Olavarría (Province of Buenos Aires).83

On the other hand UK has one of the highest death rates from CVD in Europe with 200,000 deaths annually, a third of the total 58. In England ,coronary heart disease (CHD)  kills more than 110,000 people in every year. More than 1.4 million people suffer from angina and 275,000 people have a heart attack annually. Such statistics mean CHD is the biggest killer in UK. The Government is committed to reducing the death rate from CHD, stroke and related diseases in people under 75 by at least 40 percent - to 83.8 deaths per 100,000 population  by 2010.(UK DH Department of Health). Betty McBride, Director of Policy & Communications at the British Heart Foundation said that compared to other countries in Europe, the UK remains in the "red zone when it comes to tackling premature death from heart disease.79,84

CVD Prevalence
 
Two important research studies have been made on the impact of cardiovascular diseases on the Argentine population: the national survey on Risk Factors led by the Health Minister and the CARMELA  ( Cardiovascular Risk Factors Multiple Evaluation in Latin America ) research developed by the InterAmerican Heart Foundation.15,43,90 .In Buenos Aires,according to CARMELA, 12.1 per cent of people between 25 and 64 years presented a high cardiovascular risk according to Framingham score meaning a risk above 20 per cent of suffering a myocardial infactation or a stroke in the following10 years.The same study revealed that the 25-34 years old inhabitants of Buenos Aires had their carotid arteries affected by atherosclerosis in the same proportion than the 55-65 years old inhabitants of Chile.87

Risk Factors (RF)
 
At least nine risk factors (RF) can help predict the likelihood of CHD: heredity, being male, advancing age, cigarette smoking, high blood pressure, diabetes, obesity (especially excess abdominal fat), lack of physical activity, and abnormal blood cholesterol levels. According to Dr. Gregg C.Fonarow Cardiology Professor at California University (Los Angeles,USA ) probably the three most serious RF are cigarette smoking, high blood pressure and abnormal cholesterol levels. Several of these risk factors are interrelated. Obesity, lack of exercise, and cigarette smoking can raise blood pressure and adversely influence blood cholesterol levels. Several studies suggest that exposure to environmental tobacco smoke ("passive smoking") also increases the risk of developing heart disease.8,94

Heredity (including race)
 
Researchers have identified more than 250 genes that may play a role in Coronary Artery Disease (CAD). The polygenic effect means that the genetics of CAD are extremely complicated with many different genesinfluencing a person´s risk.A mutation gene is responsible for familial hipercolesterolemia (FH). Mutations in the apo E gene affect blood levels of LDL.More than 30 mutant forms of apo E have been identified.Mutations of Apolipoprotein B-100 result in LDL staying in blood for longer than normal.People with high levels of a particle called Lp(a) in blood have higher risk of developing CAD. Mutations in the Apolipoproten A1 gene result in low HDL levels and early heart attacks.The glycoprotein IIb/IIIa gene was mutated in haslf of patients under 60 who were admitted to a hospital intensive care unit with CAD.In general, test for specific genetic mutations are not performed in CAD.100.African Americans have more severe high blood pressure than Caucasians.Heart disease is higher among Mexican Americans, American Indians, native Hawaiians and some Asian Americans. 1,66

Male sex (gender)
 
The lifetime risk of developing CHD after age 40 is 49% for men and 32% for women.The incidence of CHD in women lags behind men by 10 years for total CHD and by 20 years for more serious clinical events such as MI and sudden death. 1

Smoking
 
According to the Argentine Health Minister, about 4 million people smoke  and 40,000 die per year as a result of smoking. About 6,000 are passive smokers. Argentina is second in the world rank regarding smoking exposure at homes. 69 per cent of children are exposed to smoke at home. According to CARMELA in Buenos Aires 39.7 per cent of men and 37.7 per cent of women smoke. We are third in an internacional rank whose first position is occupied by Quito,(Ecuador) where 49.4 percent of men are smokers. 89
 
Smoking fell to its lowest recorded level in 2007, 21 per cent of the population of Great Britain aged 16 and over. Smoking is highest in the 20-24 age group (31 per cent) and lowest among those aged 60 and over (12 per cent). Married or cohabiting people smoke less (18 per cent) than singles (28 per cent). Cigarette smoking is lower among households classified as professional and managerial (15 per cent) than among those classified as routine and manual (26 per cent). Health concerns are the most commonly mentioned reason for quitting, with 86 per cent of people who want to give up mentioning at least one health reason. After health, the next most commonly mentioned reasons are costs (27 per cent), family pressure (20 per cent) and the effect on children (15 per cent).76

Obesity
 
Body mass index (BMI) is a simple index of weight-for-height that is commonly used in classifying overweight and obesity in adult populations and individuals. It is defined as the weight in kilograms divided by the square of the height in meters (kg/m2). The World Health Organization (WHO) defines "overweight" as a BMI equal to or more than 25, and "obesity" as a BMI equal to or more than 30. These cut-off points provide a benchmark for individual assessment, but there is evidence that risk of chronic disease in populations increases progressively from a BMI of 21.

Vieweg et al  found significantly higher levels of overweight and obesity among male war veterans with (PTSD) in the USA than in the general population. (J Natl Med Assoc. 2006 April; 98(4): 580–586.)

According to the CARMELA study among inhabitants of Buenos Aires obesity in men was 23.1%, in women 16-8%, diabetes 7.9 % and metabolic syndrome 21.7%. 87. About 46% of men in England and 32% of women are overweight (a body mass index of 25-30 kg/m2), and an additional 17% of men and 21% of women are obese (a BMI of more than 30 kg/m2 ). Overweight and obesity increase with age. About 28% of men and 27% of women aged 16-24 are overweight or obese but 76% of men and 68% of women aged 55-64 are overweight or obese. The percentage of adults who are obese has roughly doubled since the mid-1980's. Obesity is more common in adults employed in manual occupations, particularly in women. A quarter of women working in unskilled manual occupations have a BMI of more than 30 kg/m2 compared to one in seven of those employed in a professional role. Both men and women working in unskilled manual occupations are over four times as likely as those in professional employment to be classified as morbidly obese.103 .Several Studies have evaluated BMI as a risk factor for left ventricular remodelling and overt heart failure.
Obesity has ben consistently associated with left ventricular hypertrophy and dilation which are known precursors of heart failure. 56

Sodium
 
Patients with hypertension and diabetes are frequently salt-sensitive.Increasing dietary salt intake result in a rise in systemic arterial pressure and an increase in proteinuria, as well as a progressive risk for developing renal injury.Greater dietary salt consumption results in a rise in glomerular filtration fraction and increasing proteinuria. The pressor response to increasing dietary salt consumption in patients with diabetes and hypertension may be related to insufficient renal vasodilation. (Weir,Matthew-Mineral Electrolyte Metab 1998;24:438-445)

A recent research has shown that people consuming diets of 1,500 mg of sodium had better blood pressure lowering benefits. These lower-sodium diets also can keep blood pressure from rising and help blood pressure medicines work better.92
 
According to data of the Argentine Cardiology Association the average intake of salt of 12 g per day (4 Kg per inhabitan per year). An acceptable amount would be 5 g/day and for patients with high blood pressure is 2 g. (Shapira,Valeria-Alerta sobre el daño que provoca la sal-La Nación 20 de marzo de 2002)

On average, UK salt intakes are approximately 10.1g per day in men and 7.7g per day in women but range from 4 to 18 g per day in men and 3 to 14g per day in women.Sodium naturally present in food accounts for about 15%, and salt added to food during manufacture or processing accounts for the difference i.e. 60 to 70% of total sodium intake.19  The US sodium RDA of less than 2,400 mg is higher than the UK Recommended Nutritional Intake (RNI) whose upper limit for sodium is 1,600 mg.

Lack of physical activity
 
46.2 per cent of Argentine adults lack of physical activity. 89 . Six of every 10 Argentines lack of physical activity.93.Recent statistics suggest that seven out of ten British adults don’t do enough physical activity and this increases their risk of heart disease.16

The UK  government calculates there's been a decline of more than 20 per cent in the number of miles walked since the mid-1980s.9


Excessive alcohol intake
 
Drinking too much alcohol can raise blood pressure, cause heart failure and lead to stroke. It can contribute to high triglycerides, cancer and other diseases and produce irregular heartbeats.The risk of heart disease in people who drink moderate amounts of alcohol is lower than in nondrinkers. One drink is defined as 4 fl oz of wine or 12 fl oz of beer.1. Even low estimates of 5% or 7% of hypertension attributable to alcohol imply that there are more patients with hypertension caused by alcohol than by conventional causes of remediable secondary high blood pressure. 57. Researchers found that 45 percent of the people who began drinking before the age of 14 developed later alcohol dependence, compared with only 10 percent of those who waited until they were 21 or older to start drinking. 45 .

Since 2000 the beer intake in Argentina keeps a steady trend of 12 lt/person/year. Since 1980 the wine intake dropped 30 % but in that same period beer intake increased 500 %.The alcohol intake among youth increased 40 %.37 Certain provinces like La Pampa have a wine intake of 60.31 lt/person/year.26,38
 
In England in 2005, 73 per cent of men and 58 per cent of women reported drinking an alcoholic drink on at least one day. Thirteen per cent of men and 8 per cent of women reported drinking on every day in the previous week.Younger people were more likely to drink heavily, with 42 per cent of men and 36 per cent of women aged 16-24 drinking above the daily recommendations, compared to 16 per cent of men and 4 per cent of women aged 65 and over. Among men, 24 per cent reported drinking on average more than 21units in a week. For women, 13 per cent reported drinking more than 14 units in an average day.75. In Great Britain in 2007/8 the litres of pure alcohol per adult were Beer:4.49 ,Wine:3.80 ,Spirits:2.40, Cider:0.84, Total alcohol:11.53 .

The Familiy Expenditure Survey shows that in 2005/6, of the average weekly household expenditure on alcoholc drink of  ₤14.80, £ 8.50  was spent in on-licensed premises and £ 6.30 in off licences,including supermarkets .36

High blood pressure
 
Reducing blood pressure to an optimal level has been estimated to reduce the 10 year risk of CHD by 22.57% in an otherwise average man and 33.47% in an otherwise average woman. A long-term reduction in DBP of 5-6 mmHg has been demonstrated to correlate with a 35-40% reduction in risk of stroke.14
 
In Argentina high blood pressure prevalence is betwen 27.6 % and 28.9%. Between 50 and 59 years old its 49.7% but increases to 65% in older than 60 years old. The same results were observed in the Coronary Risk Factors Multicentrtic surveillance (EMSAC, FR) 25  It´s estimated than only 18% of hypertensive patients are well controlled.32. Prevalence of high blood pressure among the Wichi-Chorote indians at Santa Victoria Este (province of Salta, Argentina) is less than other communities like General Belgrano (39.8%) and Rauch (35.8%)but it´s very much like the one observed in other cities like La Plata (32.7%)and Córdoba (29.85% ) 23,68
 
43,625 people die from a hypertension-attributable myocardial infarctation (MI)or stroke in England each year. Hypertension also causes heart failure, peripheral artery disease and is implicated in dementia.

In the UK, the prevalence of cardiovascular disease, diabetes and hypertension is higher among Asian patients compared to the general population. Similarly, hypertension is very common among Afro-Caribbeans (The largest proportion of the African-Caribbean population in the UK are of Jamaican origin); afecting half of those aged 40 years and over.As a result of these factors these ethnic groups are at high risk of stroke and renal failure.Therefore aggressive therapy is warranted to reduce blood pressure to recognised targets.In England only around 20% of hypertensive men and 30% of hypertensivewomen receive treatment for their condition. This means that a staggering two-thirds with the condition remain hypertensive. An estimated 22,601 first MIs and at least 78,000 strokes could be prevented by reducing blood pressure to optimal levels.

In UK hypertension-attributable MIs and strokes are estimated to account for 974.4 BP per year in hospital and surgical costs. 18
Diabetes
 
In Argentina the adjusted rate of prevalence for diabetes is 7,6% 25,60. New figures by the Yorkshire and Humber Public Health Observatory reveal that more than one in ten (11.6 per cent) deaths among 20 to 79-year-olds in England can be attributed to diabetes. If current trends continue, one in eight (12.2 per cent) deaths among 20 to 79-year-olds will be attributable to the condition by 2010. This work is based on data that shows adults under 80 with diabetes are around twice as likely to die as those without the condition and women with diabetes have a greater increased risk of death compared to their male counterparts.(Medical News Today-http://www.medicalnewstoday.com/articles/117896.php).
 
There are about 35,000 deaths a year in the UK attributable to diabetes about one in twenty of all deaths. Approximately 30-80% of patients with Type 2 diabetes are also hypertensive 18

Abnormal blood cholesterol levels

Studies show that the relationship between CHD and cholesterol is continuous, and that as levels of cholesterol decrease, heart health risk continuously decreases alongside it. According to the Argentine Cardiology Association and the Argentine Cardiology Federation, in Argentina 60 per cent of cardiovascular diseases are linked to blood colesterol values above 200 mg/dl which increases 49 per cent the chances of suffering a myocardial infarct. One of every the Argentine older than 21 years has blood cholesterol values above 200 mg/dl. 30 .Based on combined data from prospective studies, triglyceride is a risk factor for cardiovascular disease for both men and women in the general population, independent of HDL cholesterol. 49,74

In UK cholesterol is the single greatest risk factor for CHD. Statistics show that raised blood cholesterol is a factor in nearly half of all CHD cases (47%). Raised cholesterol is also a major risk factor in the 110,000 strokes suffered every year in the UK. Studies have shown that a 10% reduction in cholesterol (achievable by changes in diet and lifestyle) in a 40-year-old male would lead to a 54% reduction in CHD.

The Health Development Agency recently published a report stating that "reducing cholesterol levels by even a small amount would prevent approximately 25,000 fewer deaths each year. This is quite possible". Even those individuals with a family history of high cholesterol levels can improve their health outcomes through diet and lifestyle changes. Unfortunately, only 5% of the British  population and, even more worryingly, only 4% of GPs recognise cholesterol to be the major risk factor for CHD. Most think that smoking is the greatest risk factor. (Memorandum by Cholesterol UK ( WP 85)Parliament). In UK, a study by the Care Quality Commission on the performance of 8300 GP practices and 152 primary care trusts to cut deaths from heart disease and reduce inequalities found that death rates have fallen largely because of reductions in smoking and cholesterol levels. 58

Chagas ´disease
 
Chagas disease affects 16–18 million people as of 2008, with some 100 million (25% of the Latin American population) at risk of acquiring the disease, killing around 20,000 people annually. The disease is present in 18 countries on the American continent, ranging from the southern United States to southern Argentina.

Chagas´disease is transmitted by the reduviid bug (from the Reduviidae family and the Triatominae subfamily), also known as the vinchuca. 2,4,47,95 .The insect lives in crevices and gaps in poor rural housing such as thatch, mud or adobe huts in 18 Latin American countries.In Argentina the vinchucas are found throughout the country, but are especially prevalent in northern, western and central provinces where the climate is warm or temperate but dry. The infected reduviid bug transmits a protozooan parasite named Trypanosoma cruzi through its faeces, which human victims unwittingly rub into the bite wound left by the bug, or into their eyes, mouth or nose.The parasites thus enter the victim´s bloodstream and gradually invade most organs of the body, often causing severe damage to the heart, digestive tract or nervous system.

There are 2 million people (5% of the population) infected with Chagas in Argentina The northen province of Chaco (927 war veterans with 677 wives and 2,454 sons/daughters) concentrates 15 per cent of all the cases. For every case notified there are 20 cases undiagnosed 31. Seven percent of the 600,000 annual births in Argentina are to women with Chagas´ disease. An average of four percent of these women pass the disease on to their babies.

In the province of Santiago del Estero (152 war veterans with 101 wives and 367 sons/daughters) 90 per cent of new cases are diagnosed in children less than 10 years old of which 30 per cent are less than as year old.

The province of Santa Fé has 237 war veterans,199 wives and 539 sons/daughters. In the Gato Colorado village (pop 1,500), 420 km from Rafaela (province of Santa Fe) more than 35 per cent of its population are infected with Chagas 50.

Chagas disease develops slowly as the parasite can settle in the body tissues, mainly the heart.An estimated 32 percent of those infected die from organ damages during the chronic phase.Two of every 10 cases of severe damages to the heart caused by Chagass disease occur in people between the ages of 20 and 40. Right bundle-branch block or left anterior hemiblock precedes other manifestations of chronic heart disease in the majority of cases. Progression of disease leads to cardiac dilatation and biventricular failure.Prominent feaures of advanced Chagas´heart disease include left ventricular apical aneurisma and combination of complex ventricular arrhythmias, sinus bradyarrhythmias, and intraventricular and atrioventricular conduction block.The most common  modes of death are sudden death, progressive heart failure, and to a lesser extent, embolism of mural thrombi to the brain or other organs. The prognosis for patients with Chagas´cardiomyopathy may be worse than that associated with other dilated cardiomyopathies 71. Rassi et al reported their evaluation of 424 patients with known Chagas´heart disease as the basis for a risk score to predict the likelihood of death.86

Among persons in the high-risk category the 10 year mortality was 84 percent. The two only existing drugs benznidazol and nifurtimox are very effective in newborn and breastfeeding children but only 60 to 70 per cent of adolescents and adults are succesfully treated.42 The older the patients are the greater the likelihood they will experience side effects from the drugs 21. In 2007, WHO established The Global Network for Chagas Disease Elimination to raise global awareness of the disease 20.

On July 9, 2009 Doctors Without Borders launched a campagin to raise awareness of this parasitic disease.

In the UK no cases transmitted by transfusion have been reported (UK Blood Transfusion & Tissue Transplantation Services)

Homocysteine
 
Homocysteine is an amino acid in the blood. 107 Epidemiological studies have shown that too much homocysteine in the blood (plasma) is related to a higher risk of coronary heart disease, stroke and peripheral vascular disease.Other evidence suggests that homocysteine may have an effect on atherosclerosis by damaging the inner lining of arteries and promoting blood clots. However, a direct causal link hasn’t been established.Plasma homocysteine levels are strongly influenced by diet, as well as by genetic factors. The dietary components with the greatest effects are folic acid and vitamins B6 and B12. Folic acid and other B vitamins help break down homocysteine in the body. Several studies have found that higher blood levels of B vitamins are related, at least partly, to lower concentrations of homocysteine. Other recent evidence shows that low blood levels of folic acid are linked with a higher risk of fatal coronary heart disease and stroke. Several clinical trials are under way to test whether lowering homocysteine will reduce CHD risk. Recent data show that the institution of folate fortification of foods has reduced the average level of homocysteine in the U.S. population. 

Jendricko et al recently published a cross-sectional study among 66 war veterans with PTSD, 33 without PTSD and 42 healthy volunteers measuring serum concentratons of homocysteine, total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoproteína cholesterol (LDL-C)and tryglicerides.Non smoking PTSD war veterans had higher homocysteine concentrations when compared to non smking war veterans without PTSD 53

Air pollution

Prospective epidemiologic studies showed that mortality was increased among people living in communities with elevated concentrations of fine particulate air pollution. Subsequent research has shown that particulate air pollution is statistically and mechanistically linked to increased cardiovascular disease. The Women´s Health Initiative (WHI) observational study broadens the scope by finding that nonfatal cardiovascular events are also strongly associated with fine particulate concentrations 35
 
The centre of Buenos Aires has up to 14 ppm of CO (upper limit is 9 ppm). CO together with lead and other particles has increased since 1990. 27
 
Air pollution in the UK has been a recognised problem as far back as the 13th century, when the use of coal in London was prohibited on the ground that it was prejudicial to health. During the Industrial Revolution, smog pollution in urban areas became a significant problem, due to the industrial and domestic burning of coal. 102
 
Today, both urban and rural smog pollution results from the build up of secondary photochemical pollutants such as ozone. Whilst industrial nitrogen oxides emissions have fallen in the last 15 years, emissions from road transport have grown significantly, because of the increase in the number of cars, although in the last few years the introduction of clean fuel technology has helped to reduce emissions. Similarly, emissions of particulates, carbon monoxide and volatile organic compounds (VOCs) from road transport have increased, although as for nitrogen oxides, these emissions are now starting to fall.

Obstructive sleep apnea (OSA)

Estimated prevalence of OSA among patients 30-70 years old is 4% for men and 2% for women (Instituto de Efectividad Clínica y Sanitaria-www.iecs.or.ar) Regardless of their own CAD status, people with OSA are more likely than those without OSA to have a family history of premature CAD mortality. (Apoor S.Gami et al- Familial Premature Coronary Artery Disease Mortality and Obstructive Sleep Apnea- CHEST, January 2007 vol. 131 no. 1, 118-121 ).

In UK 19-27% of patients with OSA had a motor vehicle accident due to falling asleep at the wheel. 34% of drivers who drove more than 20,000 miles a year admitted they had fallen asleep at the wheel during the previous 12 months. (1998 Guilleminot-OSA Online UK)

Neighborhood and Coronary Heart Disease

Even alter controlling for personal income, education, and occupation, living in a disadvantaged neighbourhood is associated with an increase incidence of coronary heart disease. 34 .

In Buenos Aires, Villa Soldati and Villa Lugano are the neigbourhoods where more robberies with violent assaults are observed 67,69. In 1997, the neighbourhoods of Ciudadela, Villa Ballester, San Martín, Caseros, Morón y Quilmes were considered no man´s land. In 2004 many offenses were observed as well in Belgrano, the microcenter, Balvanera, Barrio Norte and Bajo Flores (La Nación, June 6,2004). Poverty and unemployment are rampant in Villa 21-24 in Barracas (Critica 22, October, 2009). Vehicles were mostly  stolen in Ramón Falcon, Yerbal and Moldes street (CABA) –February, 2009).

n UK according to a research of a nacional insurer Nottingham has the worst burglary rate, folllowed by Hull and Leeds. Residents in Guildford were found to be the least at risk. People in SW11 in Battersea and Clapham were the most likely to have been burgled during the past five years in London, followed by those in the N8 district of Hornsey.Areas of Sheffield, Croydon and Hove also made it into the top 10 districts in which burglaries were most likely to occur 10,11,12

Psychological factors and CHD

Psychological factors may contribute not only to the evolution of coronary atherosclerosis and long-term risk of coronary heart disease, but also to the triggering of acute cardiac events in patients with advanced atherosclerosis. Acute anger, stress and depression or sadness may trigger an Acute Coronary Syndrome within a few hours in vulnerable individuals. 5,44 The psychobiological processes underlying emotional triggering may include stress-induced haemodynamic responses, autonomic dysfunction and parasympathetic withdrawal, neuroendocrine activation, inflammatory responses involving cytokines and chemokines, and prothrombotic responses, notably platelet activation. These factors in turn promote coronary plaque disruption, myocardial ischaemia, cardiac dysrhythmia and thrombus formation.39,94

Long term traumatic stress and CHD

Price published the factors leading to low rates of combat psychiatric casualties among British in the 1982 conflict 85 . Orner RJ et al reported the first available findings on long term traumatic stress syndromes among British servicemen who are veterans of the Malvinas War. 77. Then Gareth H.Jones and Jonathan W.T.Lovett published three cases of British war veterans who took part in Malvinas: A 19 years old Welsh Guard blown out of a below deck compartment on the assault ship HMS Sir Galahad by a bomb blast, a 36 years old naval steward  who was a first aid orderly on HMS Antelope when a bomb with a faulty fuse decapitated his fiend and later exploded blowing him into the water and another Welsh Guard who suffered severe burns in a bomb blast below decks on HMS Sir Galahad  and was the only survivor from one of the stern compartments.  They all demonstrated a common pattern similar to that shown by Vietnam war veterans regarding delayed psychiatric responses, particularly anxiety neuroses. 54 . Kulenovic et al determined plasma lipid parameters and calculated risk factors for 50 veterans in the PTSD group and 50 veterans in the non PTSD Group. Chronic PTSD was associated with dyslipemia, leading to an increased risk of coronary artery disease. Post MI patients with PTSD have higher sympathetic and lower parasympathetic heart rate modulation activity, compared with patients with MI and no PTSD 61

Depression
 
Depression is commonly present in patients with coronary heart disease (CHD) and is independently associated with increased cardiovascular morbidity and mortality.65. 

Depression, anxiety, and hostility have each been demonstrated to be associated with the risk of coronary heart disease and of adverse outcomes after acute coronary events. 108. Several hypotheses have been proposed to explain such associations. O´Malley et al in a prospective study of 630 consecutive consenting, active-duty US Army personnel 39 to 45 years of age without known coronary artery disease found that depression, anxiety, hostility, and stress were not related to coronary-artery calcification and that somatization was associated with the absence of calcification.(O´Malley, P. et al-The New England Journal of Medicine 2000;343 : 1298-304). In some studies, nearly half of the veterans who had PTSD were also depressed. 

The two conditions often go hand in hand, often with some overlap in symptoms. "In the group who have PTSD, depression is quite prominent, about 45 percent," reports Frank Schoenfeld, MD, the director of the PTSD program at the Veterans Affairs Hospital in San Francisco. In a study of 101 veterans with depression, a report in the Journal of Mental Disorders showed that compared to vets with no symptoms of the illness, "The depression group had experienced significantly higher numbers of traumatic incidents... and more frequently met diagnostic criteria for PTSD." 101

Emotional Stress
 
Physical exertion, burst of anger and sexual activity have been proven to have triggering potential. Other possible triggers include external and environmental events such as earthquakes, war threat and climatic factors. 109 .The Fédération Internationale de Football Association (FIFA) World Cup,held in Germany from June 8 to July 9,2006 provided an opportunity to examine the relation between emocional stress and the incidente of cardiovascular events.Viewing a stressful soccer more than doubles the risk o fan acute cardiovascular event. 110. Soccer is most popular in Argentina and UK.

Myocardial infarction and sudden cardiac death demonstrate a marked circadian variation with an increased risk during the morning after awakening and arising. Trigger factors occur relatively frequently and may play a causative role in up to 20% of cases of acute coronary syndromes.

Class and mortality

Differences in rates of premature health illness, and disability are closely tied to economic status. Class is dificcult to define.There are many ways of measuring it, the most widely accepted being in terms of income, wealth,education, and employment. Unhealthy behavior and lifestyles alone do not explain the poor health of those in lower classes. Even when behavior is held as constant as possible, people of lower socioeconomic status are more likely to die prematurely than are people of higher socioeconomic status. Some authors pinpoint income as the single most powerful predictor of mortality 62 and some analysts suggest that employment is the key socioeconomic determinant of health.13 Policies regarding education, taxes, recreation, transportation, and housing cannpt be divorced from their effects on health. Medical care has been estimated to account for only about 10 to 15 percent of the nation´s premature deaths.70 Thus, ensuring adquate medical care for all will have only a limited effect on the nation´s health.

National averages show that poverty in Argentina has been declining since 2003, when a record 54 percent of the country's 37 million people were below the poverty line after the economic and political collapse of late 2001. Statistics for late 2006 from the National Institute of Statistics and Censuses (INDEC) showed that 26.9 percent of the Argentine population was living in poverty. But in Corrientes, that figure was 46 percent. Indigence (extreme poverty) was 8.7 percent nationally, but 18.1 percent in Corrientes. Children under 14, who are more numerous in low-income families, suffer from more and deeper poverty at all levels. In the country as a whole, 40.5 percent of children are poor.

In the northeastern provinces, the proportion is 60 percent, and in Corrientes childhood poverty reaches 63.4 percent. INDEC uses two parametres to measure poverty. It defines as "indigent" people who cannot afford a basic basket of food representing their minimum "energy and protein needs." The "poor" are those who cannot afford the "complete basket" which in addition to the basic food basket contains goods and services such as clothing, transport, education and healthcare. According to INDEC's calculations, the basic food basket costs around 40 dollars a month per person in the northeastern region, while the complete basket is worth just over 85 dollars a month.

The cost of the baskets varies in different regions of the country. Indigence affects the lives of 14.3 percent of children under 14 in Argentina overall, but in Corrientes the proportion is 31 percent. 29,105

Government estimates are that 11 percent of the population cannot meet their basic food needs. Poverty rates are about 20 percent higher in the rural areas than they are in the urban areas. In the greater Buenos Aires metropolitan area the poverty rate is 29.8 percent, while in the subtropical jungle areas of the Northeast, the rate is 60 percent. The second-poorest area of the country is the mountainous region of the Northwest where the poverty rate is 53.6 percent. 3

Nearly 13 million people live in poverty in the UK that’s 1 in 5 of population. 3.8 million children in the UK are living in poverty. 2.2 million pensioners in the UK are living in poverty. 7.2 million working age adults in the UK are living in poverty. 70% of Bangladeshi children in the UK are poor. omen are the majority in the poorest groups.London has a higher proportion of people living in poverty than any other region in the UK.The UK has a higher proportion of its population living in relative poverty than most other EU countries: of the 27 EU countries, only 6 have a higher rate than the UK. 78


Social Deprivation and cardiovascular events

Woodward et al in Scotland found that the social gradient in cardiovascular event rates was inadequately reflected by the Framingham score, leaving a large social disparity in future victims not identified as high risk. ASSIGN score (derived from cardiovascular outcomes in the Scottish Heart Health Extended Cohort (SHHEC) classified more people with social deprivation and positive family history as high risk, anticipated more of their events, and abolished this gradient.111
 
Researchers at Harvard University report that lack of health insurance is taking a huge toll on US citizens and is associated with 45 000 excess deaths annually among those aged 18 to 64 years, even after controlling for factors such as smoking, obesity, race and ethnicity, income, and alcohol use.51,52,64. Among elderly people hospitalization of a spouse is associated with an increased risk of death ,and the effect of the illness of a spouse varies hmong diagnosis. Such interpersonal health effects have clinical and policy implications for the care of patients and their families 28

Prevention of CVD

The provision of information and advice relating to cardiac rehabilitation must be better tailored to the context of the specific needs, beliefs, and circumstances of patients with CHD, regardless of their ethnicity.7,33 . Potentially reversible factors that can be modified: overweight, diabetes, smoking, high blood pressure, inactivity, increased levels of LDL-cholesterol, high triglycerides, low HDL-cholesterol, large waist circumference (being ¨apple shaped ¨).
 
Nutrition
 
Trans-fatty acids are a particular kind of fat that are naturally occurring in meat and dairy products but may also be produced when plant-based oils are hydrogenated to produce solid spreads, such as margarines. They're often found in confectionery and processed food like pastry, biscuits and cakes. They've been found to have the same effect on cholesterol levels as saturated fat and should be avoided as much as possible. When reducing total fat, it's important not to cut out the heart healthy fats from your diet including mono and poly-unsaturated fats and omega-3, mostly found in plant and fish oils (eg sardines, mackerel, fresh tuna, salmon). Certain plant-derived compounds, called stanol or sterol esters have been shown to reduce cholesterol levels. Fruit and vegetables are rich in many essential nutrients including vitamins C and E and carotenoids (which are all antioxidants). Diets Rich in wholegrain food can reduce the risk of CVD by up to 30 per cent. A diet that includes at least 25g of soya per day has been associated with reductions in LDL-cholesterol and CVD. Consuming moderate amounts of alcohol between one and two units a day  has been found to reduce the risk of CVD. Alcohol can increase HDL cholesterol and makes it less likely that clots will form.(British Heart Foundation). Supplements combining folic acid and vitamins B6 and B12 did not reduce the risk of major cardiovascular events in patients with vascular disease. 98
 
A Group of European medical researchers have published a text that is an update of knowledge about the prevention of cardiovascular disease and the rehabilitation of patients with such disease. 82


Identifying premature CVD

Dr. Stanley Franklin and colleagues at the UC Irvine Heart Disease Prevention Program in conjunction with researchers at the Framingham Heart Study reviewed blood pressure data from 9,657 participants in the Framingham Heart Study who had not received antihypertensive treatment and found that the combination of low diastolic and high systolic numbers to be a superior predictor of future adverse cardiovascular events. 91
 
A low thigh circumference seems to be associated with an increased risk of developing heart disease or premature death. The adverse effects of small thighs might be related to too little muscle mass in the region. The measure of thigh circumference might be a relevant anthropometric measure to help general practitioners in early identification of individuals at an increased risk of premature morbidity and mortality. 48

Screening CVD

Professor Ian A.Scott of Princess Alexandra Hospital, Brisbane (Australia) has recently published a most interesting article on Evaluating cardiovascular risk assessment for asymptomatic people (BMJ 2009;338 : a2844). According to the Scottish Health Survey Targeted screening strategies are less costly than mass screening, and can identify up to 84% of high-risk individuals. The additional resources required for mass screening may not be justified. 63 . 16-MCT (16-row multidetector computed tomography ) is a promising non-invasive diagnostic tool for the assessment of patients with coronary artery disease, useful for the detection and characterization of the different types of plaques.(Carrascosa,Patricia-Rev. Argent. Cardiol. v.76 n.3 Buenos Aires mayo/jun. 2008). NICE has launched public health guidance to reduce premature death rates in disadvantaged areas, focusing on proactive case-finding (NICE, 2008a). The guidance recommends a number of ways, such as health sessions in community venues, to identify disadvantaged people who are at high risk of cardiovascular disease and other smoking-related diseases (New guidance aims to identify people at risk of early death. Nursing Times; 104: 40, 21-22.)

Treatments and costs of caring
Surgical treatments of CVD are:a) Percutaneous transluminal coronary angioplasty (PTCA) either balloon angioplasty or placing a stent (in some cases they incorporate drugs), b) Coronary artery bypass graft or CABG, c) Valve replacement, d) Cardiac pacemakers (including CRT, cardiac resynchronisation ) and e) Heart transplant. More recently robotic cardiac surgery is being done (Mohr FW et al-J Thorac Cardiovasc Surg 2001; 121:842-53.)

In Argentina coronary surgery with extracorporeal pump costs an average of $10.750 (Argentine pesos) (Rubio,Miguel,Insúa, Jorge T.Rev. Argent. Cardiol. v.74 n.4 Buenos Aires, jul./ago. 2006). The cost of caring for a survivor of CHD event is high these patients need a high level of post-event care, and beds in the intensive care and cardiac care units are generally considedred to be the most expensive in a hospital. Furthermore, there are the indirect costs associated with premature mortality and morbidity lost productivity, increased state dependence and cost of informal care.

CVD costs the UK economy  £29 billion a year in healthcare expenditure and lost productivity. .(UK DH Department of Health).

The total direct health care cost of CAD in the UK in 2001 was estimated to be approximately £1.8 billion. The largest cost components were drug treatment (70%) and hospital treatment (25%). Friction-adjusted indirect costs of CAD borne by society in the UK are estimated to be £702 million, or approximately 28% of the overall costs of CAD. (Arran Shearer et  al-Br J Cardiol. 2004;11(3), 2004 )


Bibliography

1. American Heart Association-Risk factors and coronary heart disease and stroke- http://www.americanheart.org/presenter.jhtml?identifier=539
2. 2-Argentina: Chagas Disease - Science Progresses but Prevention Lags-Global Information Network-July 13,2005-http://www.redorbit.com/news/health/173651/argentina_chagas_disease__science_progresses_but_prevention_lags/index.html
3. Argentina-Poverty and wealth-Encyclopaedia of the Nations-http://www.nationsencyclopedia.com/economies/Americas/Argentina-POVERTY-AND-WEALTH.html
4. Arias,Daniel.Descubren un mecanismo clave del mal de Chagas-La Nación-6 de septiembre de 2001
5. Austin,Annie-Being grumpy can hurt your heart-Negativity linked to heart disease-Suite 101-The genuine article library.
6. Badaliants IE.- Clinical therapeutic aspects of the origin and the course of atherosclerosis in the veterans of the Great Patriotic War-Adv Gerontol. 2008;21(4):633-9.
7. Bär, Nora-Prevención cardíaca cuanto antes mejor-La Nación-11 de agosto 2009.
8. Barret, Stephen-Risk Factors for Cardiovascular diseases- Quackwatch-http://www.quackwatch.com/03HealthPromotion/cardiorisk.html
9. BBC Health-What´s the right activity for me? –June 2007
10. BBC News-Crime down for third year running-Thursday, 13 April 2006
11. BBC News-Nottingham ¨UK burglary capital¨-18 April 2006
12. BBC News-Nottingham and London residents most likely to be burgled-Friday 14 August 2009
13. Blane D. Social determinants of health -socioeconomic status,social class, and ethnicity. Am J Public Health 1995;85:903-905.
14. Blood Pressure Association-Blood pressure news-UK High blood pressure rises but diagnoses increase master-26/1/09
15. Boissonet, Carlos-Rev.Argent.Cardiol. v.76 n.5 –Ciudad Autónoma de Buenos Aires, Sept-Oct 2008
16. British Heart Foundation Statistics Website-Better estimates of mortality from diabetes-http://www.heartstats.org/datapage.asp?id=1113
17. British Heart Foundation-Get active !- http://www.bhf.org.uk/keeping_your_heart_healthy/staying_active.aspx
18. British Hypertension Society-www.bhsoc.org/pdfs/hit.pdf
19. British Nutrition Foundation-Salt in the diet. http://www.nutrition.org.uk/home.asp?siteId=43&sectionId=780&parentSection=341&which
20. Chagas disease : a neglected emergency-The Lancet, Volume 373, Issue 9678, Page 1820, 30 May 2009
21. Chagas News The fight against Chagas: time to focus on patients July 9th, 2009-http://chagas-rompe-el-silencio.com/news_art0003.html
22. Ciencia Hoy- Volumen 1 - Nº 2- Febrero/Marzo 1989- http://www.cienciahoy.org.ar/hoy02/chagas1.htm
23. Coghlan,Eduardo, Bella Quero,Luciana, Schwab,Marcos, Pellegrini,Débora, Trimarchi,Hernán-Prevalencia de hipertensión arterial en una comunidad aborigen del norte argentino- Medicina (B. Aires) v.65 n.2 Buenos Aires mar./abr. 2005
24. Cohen BE, Marmar C, Ren L, et al. -Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA 2009 Aug 5; 302(5):489-92.
25. Consejo Argentino de Hipertensión Arterial y Sociedad Argentina de Diabetes-Normativa:Hipertensión y Diabetes
26.  Consumen más alcohol otros países-La Nación 20 de octubre de 2009
27. Contaminación de aire en la Argentina- http://www.geocities.com/RainForest/2713/cairargs.htm
28. Christakis,Nicholas and Allison,Paul-Mortality after the hospitalization of a spouse-The New England Journal of Medicine-2006;354:719-30.
29. Cruces,Guillermo and Wodon,Quentin-Riskj-Adjusted poverty in Argentina:Measurement and determinants-Discussion Paper-Nº DARP 72,September 2003
30. Czubaj , Fabiola-El colesterol causa el 60% de las enfermedades cardiovasculares-La   Nación ,29 de septiembre 2009.
31. Czubaj , Fabiola-Estamos perdiendo la batalla contra el mal de Chagas-La Nación, 19 de noviembre de 2008
32. Czubaj,Fabiola-Solo el 18% controla bien la hipertensión-La Nación-15 de septiembre de 2009
33. Darr A.,Astin K.,- Causal attributions, lifestyle change and coronary heart disease: illness beliefs of patients of South Asian and European origin living in the UK-. Heart & Lung -The Journal of Acute & Critical Care, 37 (2). pp. 91-104. ISSN 0147-9563
34. Diez Roux,Ana et al-Neighbourhood of residence and incidente of coronary heart disease-The New England Journal of Medicine 2001:345:99-106
35. 35.    Dockery,Douglas,Sc.D., and Stone,Peter H.MD-Cardiovascular risks from fine particulate air pollution-The New England Journal of Medicine 356:5,February 1,2007
36. 36.    Drinking in Great Britain-IAS Factsheet-Institute of Alcohol Studies
37. El consumo de alcohol en la juventud creció un 40%-La Arena.com.ar. http://www.laarena.com.ar/la_ciudad-el_consumo_de_alcohol_en_la_juventud_crecio_un_40_-29769-115.html
38. Estadisticas del consumo de alcohol en Argentina. http://html.rincondelvago.com/estadisticas-del-consumo-de-alcohol-en-argentina.html
39. Fahrer, Rodolfo-10º  Congreso Internacional de Psiquiatría – 21 al 24 de Octubre de  2003, Buenos Aires, Argentina.
40.  
41. Escobar,Edgardo-Prevención de Enfermedades Cardiovasculares en Latinoamérica-   Universidad de Chile,Santiago, Chile.
42. Fairlamb,AH-Future prospects for the chemotherapy of Chagas' disease. Medicina (B Aires). 1999;59 Suppl 2:179-87.
43. Ferrante D, Virgolini M. Encuesta Nacional de Factores de Riesgo 2005: Resultados principales. Prevalencia de factores de riesgo de enfermedades cardiovasculares en la Argentina. Rev Argent Cardiol 2007;75:20-9.
44. Ginzburg K, Ein-Dor T, Solomon Z - Comorbidity of posttraumatic stress disorder, anxiety and depression: A 20-year longitudinal study of war veterans.- J Affect Disord 2009 Sep 16
45. Grant, B.F.; and Dawson, D.A. Age at onset of alcohol use and its association with DSM–IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse 9:103–110, 1997. PMID: 9854701.
46. Gulf War and health: Volume 6-Physiolohic, Psychologic and Psychosocial effects of deployment related stress-The National Acdemies Press-Committee on Gulf War and Health
47. Hallan Chagas en momias de 9000 años-La Nación ,8 de febrero de 2004
48. Heitmann,Berit L., Fredericksen,Peder- Thigh circumference and risk of heart disease and premature death: prospective cohort study- BMJ 2009;339:b3292
49. Hokanson,John, Austin,Melissa A.- Plasma trigliceryde level is a risk factor for cardiovascular disease independent of high-density lipoprotein cholesterol level:a meta-analysis of population-based prospective studies-European Journal of Cardiovascular Prevention & Rehabilitation-J Cardiovasc Risk. 1996 Apr;3(2):213-9
50. Grande,Emilio-En Gato Colorado,más del 35% es chagasico-La Nación,12 de septiembre de 2002
51.  Ikin JF, Sim MR, McKenzie DP, Horsley KW, Wilson EJ, Harrex WK, Moore MR, Jelfs PL, Henderson S - Life satisfaction and quality in Korean War veterans five decades after the war. [Journal Article, Research Support, Non-U.S. Gov't] J Epidemiol Community Health 2009 May; 63(5):359-65.
52. Isaacs,Stephen L. and Schroeder,Steven-Class-The ignored determinant of the Nation´s health-The New England Journal of Medicine-351;11, September 9,2004.
53. Jendrièko T, Vidoviæ A, Grubišiæ-Iliæ M, Romiæ Z, Kovaèiæ Z, Kozariæ-Kovaèiæ D - Homocysteine and serum lipids concentration in male war veterans with posttraumatic stress disorder.-Prog Neuropsychopharmacol Biol Psychiatry 2008 Nov 14.
54.  Jones,Gareth H. and Lovett,Jonathan W.T—Delayed psychiatric sequelae among Falklands veterans-Royal College of General Practitioners-1987 January;37(294):34-35
55. Kang HK, Li B, Mahan CM, Eisen SA, Engel CC - Health of US Veterans of 1991 Gulf War: A Follow-Up Survey in 10 Years. J Occup Environ Med 2009 Mar 24.
56. Kenchaiah,Satish et al-Obesity and the risk of heart failure-The New England Journal of Medicine-Vol 347,Nº 5-August 1,2002
57. Klatsky AL. Alcohol and hypertension. In: Oparil S, Weber M, eds. Hypertension. Philadelphia, PA: WB Saunders Co; 2000: 211–220.
58. Kmietowicz, Zosia- Doctors needs tougher targets to reduce heart disease further, says watchdog-BMJ 2009;339:b3852
59. Kulenoviæ,Alma Džubur et al-Changes in plasma lípido concentrations and risk of coronary artery disease in Army Veterans suffering from chronic postraumatic stress disorder-Croat Med J 2008;49:506-14
60. La diabetes en America Latina-MSD-Sala de Prensa,Abril 2007- http://www.msd.com.ar/msdar/corporate/press/diabetes/noticia2.html
61. Lakusic et al-Characteristics of heart-rate variability in war veterans with Post-Traumatic stress disorder after myocardial infarctation, Military Medicine-November 2007
62. Lantz PM, House J, Lepkowski JM, Williams DR, Mero RP, Chen J.Socioeconomic factors, health behaviors, and mortality: results from anationally representative prospective study of US adults. JAMA1998;279:1703-1708.
63. Lawson,Kenny D ,Fenwick,  Elisabeth AL,, Pell, Alastair CH , Pell, Hill- Comparison of mass and targeted screening strategies for cardiovascular risk: Simulation of the effectiveness, cost-effectiveness and coverage from a cross-sectional survey of 3,921 people.- Heart. Published Online First: 7 September 2009.
64. Lenzer,Jeanne-Lack of health insurance leads to 45 000 excess deaths in US-BMJ 2009;339:b3838
65. Lichtman,Judith H. et al.-Depression and coronary heart disease- Circulation. 2008;118:1768-1775.
66. Lopez-Quintero C, Berry EM, Neumark Y.- Limited English proficiency is a barrier to receipt of advice about physical activity and diet among Hispanics with chronic diseases in the United States.- J Am Diet Assoc. 2009 Oct;109(10):1769-74.
67. Los barrios del sur de la ciudad son considerados los mas inseguros-17-07-2007- Los datos surgen de una encuesta sobre “victimización” realizada por Gobierno de la Ciudad de Buenos Aires. http://www.alertamilitante.com.ar/visualiza.php?nota=77
68. Luquez, Hugo, Madoery, Roberto, De Loredo, Luis.De Roitter, Hebe, Lombardelli, Sonia,Capra,  Raul ,Zelaya, Hugo Prevalencia de Hipertensión Arterial y factores de riesgo asociados.Estudio Dean Funes (Provincia de Cordoba)- Rev Fed Arg Cardiol 28, 93-104, 1999
69. Mapa de Distritos y Regiones Educativas de la Provincia de Buenos Aires -abc.gov.ar/lainstitucion/.../MAPA%20REGIONES%20A3.pdf
70. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21:78-93.
71. Maguire,James H-Chaga´s disease-Can we stop the deaths ?-The New England Journal of Medicine-Volume 355:760-761, August 24,2006-Number 8
72. Marsh AR-A short but distant war - the Falklands campaign. J R Soc Med 1983 Nov; 76(11):972-82.
73. Martínez, Carlos A. - Kriskovich Jure, Jorge O. - Herdt, Alejandra E. Lopez Campanher, Adolfo G. - Ibarra, Rosa A. - De Bonis, Griselda R. - Correa, Liliana M.-Cátedra de Semiotecnia y Fisiopatología - Facultad de Medicina - UNNE.- Universidad Nacional del Noreste-Comunicaciones Científicas y Tecnológicas 2000.
74. National Colesterol Education Program-Risk Assessment Tool for Estimating 10-year  Risk of Developing Hard CHD (Myocardial Infarction and Coronary Death)-   http://hp2010.nhlbihin.net/atpIII/calculator.asp?usertype=prof
75. National health Service-Statistics on Alcohol: England 2007 [NS]- http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/alcohol/statistics-on-alcohol:-england-2007-%5Bns%5D
76. National Statistics UK-Smoking-http://www.statistics.gov.uk/cci/nugget.asp?id=866   
77. Orner RJ, Lynch T, Seed P-Long-term traumatic stress reactions in British Falklands War veterans. -Br J Clin Psychol 1993 Nov.:457-9.
78. Oxfam-UK Poverty Facuss-http://www.oxfam.org.uk/resources/ukpoverty/povertyfacts.html
79. Paddock,Catharin-UK Among Losers In Europe's Heart Disease League Table-Medical News Today-http://www.medicalnewstoday.com/articles/163589.php
80. Parliament www.Parliament UK-Select Committee on Health Written Evidence-Memorandum by Cholesterol UK (WP 85)
81. Patrick DL, Heaf PJD-Long-term effect of war related deprivation on health: a report on the evidence-London British Members´Council of the World Veterans Foundation  1982
82. Perk,Joep, Mathes,Peter and Gohlke,Helmut-Cardiovascular prevention and rehabilitation-London, Springer-Verlag 2007-ISBN  978-1-84628-462-5
83. Pitarque,Raúl, Bolzán, Andres, Gatella, María E, Echaide, María E, Guanuco,   Silvina, Arias, Marcela, Murillo, Mirta, Ortiz, Zulma- Factores de riesgo de enfermedad cardiovascular en la población adulta de la ciudad de Olavarría, Buenos Aires-Rev. Argent. Cardiol. v.74 n.6 Buenos Aires nov./dic. 2006
84. Pocock, Stuart et al-A score for predicting risk of death from cardiovascular disease in adults with raised blood pressure, based on individual patient data from randomised controlled trials-BMJ 2001;323:75-81 ( 14 July )
85. Price HH -Rate of British psychiatric combat casualties compared to recent American wars-J R Army Med Corps 2007.:58-61; discussion 62.
86. Rassi, Anis Jr et al-Development and Validation of a Risk Score for Predicting Death in Chagas'  Heart Disease-The New England Journal of Medicine-Volume 355:799-808, August 24,2006-Number 8.
87. Rios,Sebastián-Buenos Aires primera en riesgo cardiaco-La Nación 12 de marzo 2008
88. Ríos,Sebastián-La atención de un infarto suele demorar más de 5 horas-La Nación-1º de octubre de 2009.
89. Ríos,Sebastián-Las costumbres argentinas no son saludables-La Nación-5 de Octubre de 2009
90. Schargrodsky H, Hernández-Hernández R, Champagne BM, Silva H, Vinueza R, Silva Ayçaguer LC, et al; CARMELA Study Investigators. CARMELA: assessment of cardiovascular risk in seven Latin American cities. Am J Med 2008;121:58-65.
91. Systolic And Diastolic Blood Pressures Together More Useful For Predicting Cardiovascular Risk-Science Daily (Feb. 19, 2009)
92. Sodium Recommended Daily Allowance- http://www.annecollins.com/sodium-rda-diet.htm
93. Son sedentarios 6 de cada 10 argentinos-Encuesta de TNS Gallup-La Nación-30 de septiembre de 2007
94. Steptoe,A.,Brydon,L.- Emotional triggering of cardiac events.- Neurosci Biobehav Rev  2009 Feb;33(2):63-70.Epub 2008 May
95. Storino,Ruben- Salud Futura-Epidemiologia de la Enfermedad de Chagas en la Argentina-8 de julio de 2007-http://www.saludfutura.com.ar/SF/index.php?option=com_content&task=view&id=16&Itemid=9
96. Tartaglione J, Grazioli GC, Sarmiento M, Goldstraj LM. Eventos cardiovasculares en una población cerrada. Seguimiento a 10 años. Rev Argent Cardiol 2008;76:347-51.
97. The Burden of Cardiovascular disease in New York:Morality, prevalence, risk factors, costs and selected population-http://www.health.state.ny.us/nysdoh/chronic_disease/cardiovascular/burdenofcvdinnys.pdf
98. The Heart Outcomes Prevention Evaluation(HOPE)2 Investigators-Homocysteine lowering with folic acid and B vitamins in vascular disese-The New England Journal of Medicine 2006;354:1567-77-
99. The Royal Navy´s role in Britain´s  last colonial war-The Falklands War-Military History Study Group- http://www.probusmossvale.org.au/Military%20History_files/Falklands/Falklands3.pdf
100. Trelogan,Stephanie-Genes can cause coronary artery disease-Gene ticHealth, September 12,2000-http://www.genetichealth.com/HD_Genetics_of_Coronary_Artery_Disease.shtml
101. Udesky,Laurie-PTSD and Depresion in Veterans- http://www.ahealthyme.com/topic/depvet#s18
102. UK Air Pollution- http://www.ace.mmu.ac.uk/eae/air_quality/older/UK_Air_Pollution.html
103. UK Obesity Statistics-http://www.annecollins.com/obesity/uk-obesity-statistics.htm
104. University of Maryland-Heart Disease Risk Calculador-http://www.healthcalculators.org/calculators/heart_disease_risk.asp
105. Valente, Marcela-Argentina: Poverty bites deeper in the Northeast-http://ipsnews.net/news.asp?idnews=38324
106. War trauma scars pose risk of heart disease-Bio-Medicine.  http://www.bio-medicine.org/medicine-news/War-Trauma-Scars-Pose-Risk-of--Heart-Disease-17061-1/
107. What is homocystein? –American Heart Association-October 17,2009- http://www.americanheart.org/presenter.jhtml?identifier=535
108. Whooley, Mary A.- Depression in Patients With Cardiovascular Disease-To screen or not to screen? - J Am Coll Cardiol, 2009; 54:891-893, –
109. Willich SN, Klatt S, Arntz HR.- Circadian variation and triggers of acute coronary síndromes-Eur Heart J. 1998 Apr;19 Suppl C:C12-23
110.  Willbert-Lampen,Ute et al-Cardiovascular events during World Cup Soccer-The New England Journal of Medicine 2008;358:475-83
111.  Woodward,Mark, Brindle,Peter, Tunstall-Pedoe, Hugh-Adding social deprivation and family history to cardiovascular risk assesment:the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC)-Heart 2007;93:172-176